WEEK 10 OSPAP Programme

Respiratory Examination & History

Slide 1 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 The Beginning!

• Environment! • Introduce yourself • Ask permission to take the history • Have you got the correct person!! • Patients Demographics – Name – Age – Occupation – Background

Slide 2 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Initiating the Session: • Preparation • Establishing initial rapport • Identifying reason for the consultation

Gathering Information: Building the Providing • Exploration of the patient’s problem to discover the: Structure: • Biomedical perspective relation ship: • Patient perspective • Making • Background information (context) • Using organisation appropriate overt non-verbal Physical Examination behaviour • Attending to flow • Developing rapport Explanation and planning: • Providing the correct amount and type of information • Involving the • Aiding accurate recall and understanding patient • Achieving a shared understanding: incorporating the patient’s illness framework • Planning, shared decision making

Closing the session: • Ensuring appropriate point of closure • Forward planning

Kurtz S, Silverman J, Benson J, Draper J (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Medicine;78(8):802-809

Slide 3 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Structure

• Presenting Complaint • History of Presenting Complaint Polly (Peter) Has • Past medical history Pretty Damn • Drugs (medications/allergies) Fine Sexy (smelly) • Family history Stockings (socks) • Social history • System enquiry

Slide 4 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 OPQRSTU

• O Onset • P Pain, precipitating factors • Q Quality, quantity • R Radiation, relieving factors • S Severity/score, symptoms • T Timing • U You (ICE)

Slide 5 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 I.C.E.

• Ideas – “Do you have any particular worries about this symptom?”

• Concerns – “What is concerning you?”

• Expectations – “What are you hoping for me to do for you today?”

(Moulton 2007)

Slide 6 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Past Medical History

Open questions What illnesses have you had? (include psychiatric conditions if appropriate)

Slide 7 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 History Taking

Drug History

• Not just prescribed drugs - include over the counter remedies and alternative medicine • Name each substance, dose and duration • Compliance • Drug allergies & sensitivities

Slide 8 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Medication and Allergies

• Medication – Generic name if possible – Dose – Route of administration – Recent change – Include OTC and homeopathic / herbal – Recreational drugs • Allergies & Sensitivities – When? Diagnosed? – How presented, symptoms

Slide 9 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 History Taking

Family history • Open question - ‘tell me about any illness(es) which run in the family • Ask specifically about immediate family including parents • Diagnosis and age • Cause of death

Slide 10 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Social History

• Family situation • Relationships incl. Marital status • Occupation – Past and present – Exposure • Community Involvement & Network • Hobbies

Slide 11 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Social History

Alcohol history Quantity and type Place of drinking Alone or accompanied Money spent Purpose

Slide 12 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Social History

Tobacco Duration Type - pipe, cigarettes, cigars Amount If stopped when

Slide 13 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systematic Inquiry

General Well being Appetite Sleep Energy Weight change

Slide 14 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systemic Enquiry

• Direct questioning • Organise symptoms by system • Explore any positives with open ended questions and then clarify as per presenting complaint • Use lay terms • Summarise • Anything else?

Slide 15 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systemic Enquiry

C.V.S. • Chest pain • Breathlessness – On exertion – Lying flat – Wake up at night – Orthopnoea • Palpitations • Ankle swelling • Exercise Tolerance • Pain in legs when walking

Slide 16 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systemic Enquiry

R.S. • Shortness of breath • Chest pain – On inspiration • Cough • Sputum – Blood • Wheeze

Slide 17 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systemic Enquiry

GI System • Dental / Gum Problems • Reduced appetite/weight loss • Swallowing – painful – difficult • Indigestion, heartburn • Abdominal pain • Vomiting • Altered bowel habit • Blood loss

Slide 18 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systemic Enquiry

Urogenital Pain on passing urine Frequency - day, night Colour of urine Males: (age), difficulty starting, poor stream, dribbling, discharge, libido Females: menarche, menopause, frequency, regularity, urge or stress, incontinence, discharge, abnormal bleeding, libido

Slide 19 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systemic Enquiry

CNS • Weakness • Disturbance of sensation • Headaches • Visual disturbance • Dizziness, blackouts (clarify these) • Fits • Confusion • Disturbance of speech • Hearing

Slide 20 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systemic Enquiry

Locomotor • Joint Pain • Joint Stiffness • Swelling • Mobility • Gait • Falls • Redness and warmth

Slide 21 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systemic Enquiry

Endocrine • Heat intolerance (change) • Cold intolerance (change) • Change in sweating • Thirst and Polyuria • Prominence of eyes (change) • Swelling in neck • Energy

Slide 22 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Systemic Enquiry

The Skin • Rash • Spots • Itching • Ulcers • Lumps/growths

Slide 23 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Summary

• Salient features of – Presenting history – Relevant past history – Background • Differential diagnosis

Slide 24 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 History Taking

Explanation • Most important from the patients point of view • Communication skills are vital • Speak clearly and audibly • Avoid jargon • Avoid emotive words • Most important information first

Slide 25 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Examination

Includes: General inspection Specific inspection (hands, face, chest) Palpation Percussion Auscultation Additional checks

Slide 26 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Inspection

• General inspection • Hands • Face • Eyes • Mouth • Anterior chest • Posterior chest

Slide 27 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Palpation

• Lymph nodes • Trachea • Anterior chest • Posterior chest

Slide 28 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Percussion

• Explain purpose of percussion – Identifying areas of tympany & dullness • Identify appropriate percussion points • Use correct percussion technique – Compare side to side, identifying percussion note • Posterior chest –As per anterior chest

Slide 29 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Auscultation

• Explain purpose of auscultation- asks pt to breathe through mouth

• Identify normal /abnormal breath sounds and causes – bronchial, vesicular, crepitations, wheeze, pleural rub

• Identify appropriate auscultation points – Takes time to Listen thru full respiratory cycle at identified auscultation points

• Demonstrate correct auscultation technique with diaphragm placed firmly on chest wall

• Demonstrate vocal resonance – Correct vocal resonance technique

• Posterior chest: – As per anterior chest

Slide 30 of 49 MPHM14 OSPAP Clinical Skills WEEK 10 Additional checks

• Sacral oedema (as in heart failure) • Inspect both legs: – Calf pain – Leg swelling – Palpate calves for tenderness DVT – Increased temp of leg – Inflammation • Thank the pt

Slide 31 of 49 MPHM14 OSPAP Clinical Skills

WEEK 10 Recap

Examination: History:  General inspection  Presenting Complain  Specific inspection  Hx PC (OPQRSTU) (hands, face, chest)   Palpation Prev Med Hx  Percussion  Drug Hx  Auscultation  Family Hx  Additional checks  Social Hx  Systems Review

Slide 32 of 49 MPHM14 OSPAP Clinical Skills WEEK 10

Slide 33 of 49 MPHM14 OSPAP Clinical Skills